222 BAYSIDE DR FEDERAL EMERGENGY MNNAGEMENI AGkNI;Y O.M.B. No. 3067-0077
NATICINAL FLOOD INSURANCE PROGRAM Expires December 3'i, 2005
ELEVATION CERTIF�CATE
!m artant: Read the instructiar�s an a es 1 - 7.
SECTION A-pROPERTY OWNER INFORMATION For Irtsurance Company Use;
Palicy Numb�r
1NG OWNER'S NAME
�k Ploc�
������tj 8.�S 1�2A 1J r'1 V e Including Apt.,Unit,Suite,andlor Bldg.No,)QR P.O. ROUI"E AND BOX NO. Company NAIC Number
FSlorida �����./
��1Tearwater
AROPERTY DESCRiPTION(Lot and Block Numbers,Tax Parcel Numher,Legal Description,etc.)
Lot F
UILDI G U E,(e. ,Residentiat,Non-residential,AddiUon,Accessory,etc. Use a Camments area,if necessary.)
I�esi�en�la�
LATITUDEILONGITUDE(OPTIONAL) HORIZONTAL DATUM: gp�}RCE: �_�GPS(lype):
( �k�°-�s'-##.##" or #�.�#�##°) �_�NAD 1927 �_�NAD 1983 �_�USGS Quad Map ���Other
SECTION B- FLOOD INSURANCE RATE MAP(FIRM) INFORMATION
83.STATE
B1. NFIP COMMUNITY NAME&CQMMUNITY NUMBER B2.COUNTY NAME Florida
City of Clearwater 125�96 Pinellas
84. MAP AND PANEL B5.SUFFIX B6.FIRM 1NDEX 87.FIRM PANEL B8.FLOOD BZone AO,u e�depth of flood ng)'
NUMBER DATE EFFECTIVE/REVISED DATE AE NE(S) 1�1
12103C0102G G May 17, 200 Sept.3 ,2003
B10. indicate the source of the Basa Flood Elevation (BFE)data or base flood depth entered in B9.
�_� FIS Profile �.� FIRM �_� Community Determined �.��Othar(Describe):
B1'I. lndicate the elevation datum used for the BFE in B9: �_� NGVD 1929 ��� NAVD 1988 �_� Other(Describe):
8�2. is the building located in a Coastal Barrier Resources System(CBRS) area or Otherwise Protected Area (OPA)? �_� Yes �� No
Designation Date:
SECTION C -BUILDING ELEVATION INFORMATION (SURVEY REQUIRED)
C"I. Building elevations are based on: �_..IGonstruction Drawings` �_�Building Under Gonstruction` �.�Finished Construction
` . new Elevation Certificate wili be required when construction of the building is complete.
C�ilding Diagram Numbar_ �(Select the building diagram most similar to the building for which this certificate is being comp(eted-s tj
pages 6 an d 7. I f na d ia g r a m a c c u r a t e l y r e p r e s e n t s t h e b u i l din g,provide a sketch or photograph.�
C3. Elevations–Zones A1-A30, AE, AH,A(with BFE),VE,V1-V30,V (with BFE),AR,AR/A, ARIAE, AR/A1-A30, AR/AM, AR/AO
Complete ltems C3.a-i below according to the buiiding diagrarn specified in Item C2. State the datum used. If the datum is different from
the datum used far the BFE in Section B, convert the datum to that used for the BFE. Show field measurements and datum conversion
caiculation. Use the space provided or the Comments area of Section D or Section G,as a�propriate,ta document the datum conversion.
Daturn Conversion/Comments Y�
Elevation refarence mark used C o�m P n�__ Does the elevation reference mark used appear on tMe.FtC��} !.�I No
5 7 it.(m) � _' s ' �' `>�"< -
r� a) Top of bottom floor (including basement or e[t�losur ) � ,� �.
Not �ccessi�Te `ft.(m) � ` "k" s, •
Ci b) To of next hi her floor w � :� �. ` � ��'" �` ^� �;,
P � N A ft�lm� �Q s � i ' fl�
�] c) Bottom of lowest horizontal structural member(V zones only) 5— — � ��'�. , -
. 1 ft.(m) t G `�°� ; I,_ /=v.� � `� �,.,,..._
� d) Attached garage (top of slab) w � ,' s ��„ �,;y � °
�7 e) Lowest elevation of machinery andlor equipment 5 5 ��m� A� �.', � � �,,��,, '
� � � .'^F ,� !�1�/r
servicing the buiiding (Describe in a Comments area.) t < �e ��:� }�
-�ft.(m) z.� �� d� i '>
� � Lowest adjacent (finished)grade (LAG) � .,
� g) Highesi adjacent(finished) grade (HAG) � 5 3 ft.(m) �N ' ��'� " ` � ;
❑ h) IVo. of p�rmanent openings (flood vents}wfthin 1 ft.above ad�acent grade
p � � .if � " ;.�
❑ i) Total area of all permanent openings (flood vents) in G3.1� sq. in. (sq.cm)
SECTION D-SURVEYOR, ENGINEER, OR ARGHITECT CERTIFICATION `
This certification is to be signed and sealed by a land surveyor, engineer,or architect authorized by law to certify elevation information.
/certify that the information in Sect+ons A, B, and C on this certificate represents my best effons to interpret the data avai/ab/e.
/understand that an fals stat ptent ma,.be unrshable b fine orim risonment under 18 U.S. Code, Section 70D9.
CERTIFIER'S NANI s`+ '' ''" LICENSE NUM[3ER LS �086
-�1;�����-�- ����. �.,ker
71TLE ""^`'� ' CnMPANY NAM
'�:�` L�rid Su�u'e��or: Michael aker Associates
ATE IP GQDE
— .ESS ��, ���p ��-��� .��,f�'ord Ave . �'arpon Sprin s �lorida �4C�zs9
LE EPHONE
si�rvAruRE;;� �` .��, �- � '"� ` � � ��u ust 4, 2005 '1�7-938— 026
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IMPORTANT: !n these spaces, copy the corrosponding information from Section A. For Insurance Company Use:
BUILDING STREET ADDRESS (Including Apt., Unit, Suite, andlor Bldg. No.)OR P.O. ROUT�AND BOX NO. Policy Number
222 Bayside Drive -- --
CITY STATE ZIP COQE Company NAIC IJumber
Clearwater Florida 76 - - _
SEC710N D-SURV�YOR, ENGINEER, OR ARCHITECT CERTIFICATION (CONTINUED)
Copy both sides of this Elevation Certificate for(1) community official, (2)insuranco agenUcompany, and (3) building owner. •
C���levations Referenced to Pinellas Counfy BPn�hmark �P15 _1968"
Elevation= L,.. 19 Feet NAVD88
C3e : Air Conditioner
�_� Check here if attachment.�
SECTION E - BUILDING ELEVATION INFORMATION (SURVEY NOT REQUIRED) FOR ZONE AO AND 20NE A (WITHOUT BFE) _
For Zone AO and Zone A (without BFE), complete Items E1. through E4. If the Elevation Certificate is intended for use as supporting
information for a LOMA or LOMR-F, Section C must be completed.
E9. Building Diagram Number (Select the building diagram most similar to the building for which this certificate is being compleied—
see pages 6 and 7. If no diagram accurately represonts the building, provida a sketch or photograph.)
E2. The top of the bottom floor(including basement or enclosure)of the building is �_�T�ft.(m) I.—I_lin.(cm) (T� above or �`� below
(check one) the highest adjacent grade. (Use natural grade, if available.)
E3. For Building Diagrams 6-8 with openings (see page 7), the next higher floor or elevated floor(elevation b) of the building is
I�I_I ft•tm) I-1—I�n.(cm) above the highest adjacent grade. Complete Items C3.h and C3.i on front of form.
E4. For Zone AO only: If no flood depth number is available, is the top of the bottom floor elevated in accordance with the community's
floodplain management ordinance� � � Yes � � No � � Unknown. The local official must certify this information in Section G. _ __
SECTION � - PROPERTY OWNER (OR OWNER'S REPRESENTA7IVE) CERTIFICATION _ _ _
The property owner or orvner's authorized representative who completes Sections A, B, C (Items C3.h and C3.i only), and E for Zone A
(without a FEMA-issued or community-issued BFE) or Zone AO must sign here. The statements in Sections A, B, C, and E are corr�ct to
the best of my knowledge.
PROPERTY OWNER'S OR OWNER'S AUTHORIZED REPRESENTATIVE'S NAME
ADDRESS CITY STATE ZIP CODE
SIGNATUftE DATE TELEPHONE �—
_
COMMENTS _
��� Check here if attachments
SECTION G -COMMUNITY INFORMATION {OPTIONAL) _ _
The local official who is authorized by law or ordinance to administer the communiiy's floodplain management ordinance can complete
Sections A, B, C (or E), and G of this Elevation Certificate. Complete the applicable item(s)and sign below.
G1. �_�l"he informatiori in Section C was taken from other documentation that has been signed and embossed by a licensed surveyor,
engineer, or archi±�ct who is authorized by state or local law to certify elevation information. (Indicate the source and date of the
elevation datl in tha Comments area below.)
G2. j_j A community o��icial completed Section E for a building located in Zone A(without a FEMA-issued or community-issued BFE) or
Zone AO.
G3. �_� Tha following information (Items G4-G9) is provided for communily floodplain management purposes.
G4. PERMIT NUMB�R G5. DATE PERMIT ISSUED G6. DATE CERTIFICATE OF COMPLIANCElOCCUPAhiCY
�SSUED
G7. This permit has been issued for: �_� New Construction �_� Substantial Improvement
G8. Elevation of as-built lowest floor(including basement)of the buiiding is:
_ft.(m)Datum:
G9. BFE or(in Zone AO) depth of flooding at the building site is: —
ft.(m)Datum:
LOCAL OFFICIAL'S NAME TITLE
COMMUNITY NAME TELEPHONE
SIGNATURE DATE _
COMMENTS
--
�__� Check here if attachments
REPLACES ALL PREVIOUS EDITIONS
FEMA For, : 81-31, JUL 00